2004-559 TOWN OF QUEENSBURY
742 Bay Road,Queensbury,NY 12804-5902 (518)761-8201
Community Development - Building & Codes (518) 761-8256
CERTIFICATE OF COMPLIANCE
Permit Number: P20040559 Date Issued: Tuesday, July 27, 2004
This is to certify that work requested to be done as shown by Permit Number P20040559.
has been completed.
Tax Map Number: 523400-316-013-0001-026-000-0000
Location: 6 BARDIN Dr
Owner: CLINTON & JUDY TRAVER
Applicant: CLINTON & JUDY TRAVER
This structure may be occupied as a:
By Order of Town Board
Septic Alteration Residential TOWN OF QUEENSBURY
Director of Building&Code Enforcement
TOWN OF QUEENSBURY
742 Bay Road,Queensbury,NY 12804-5902 (518)761-8201
Community Development-Building& Codes (518) 761-8256
BUILDING PERMIT
Permit Number: P20040559 Application Number: A20040559
Tax Map No: 523400-316-013-0001-026-000-0000
Permission is hereby granted to: CT,TNTON&T1JDY TRAVF,R
For property located at: 6 BARDIN Dr
in the Town of Queensbury,to construct or place.
at the above location in accordance with application together with plot plans and other information hereto filed
and approved and in compliance with the NYS Uniform Building Codes and the Queensbury Zoning
Ordinance. Type of Construction Value
Owner Address: CLINTON& JUDY TRAVER Septic Alteration Residential
6 BARDIN Dr Total Value
QUEENSBURY, NY 12804
Contractor or Builder's Name /Address Electrical Inspection Agency
I.B.S. SEPTIC
2 LOWER WARREN STREET
OTTEENSBURY_ NY
Plans&Specifications
04-559
SEPTIC ALTERATION
$25.00 PERMIT FEE PAID-THIS PERMIT EXPIRES: Tuesday, July 19, 2005
(If a longer period is required,an application for an extension must be made to the code Enforcement Officer
of the Town of Queensbury before the expiration date.)
Dated at the Town u nsb Mo a July 19, 2004
SIGNED BY 0 for the Town of Queensbury.
Director of Building&Code Enforcement
Application for P9-111it—Septic Disposal System
Town of Queensbmy 742 Bay Road Queensbill:K NY 12804 (518) 761-8256
1. OWNER INFORMATION;
T �Q V d� -vc once Use
Location of installation:� � Cl- J
File Permit No. v
Tax Map No��/ -3 / ) (;�b G
// Fee Paid
-
Owner's Name:
, ,
Address: 4t 6 �-
T
2. INSTALLER'S NAME : y• 0, /r r / r PHONE NO. e�
3. RESIDENCE INFORMATION: (circle year of dwelling, indicate It bedroom(~) and multiply 11 of
bedrooms with applicable gallons per bedroom to equal total daily floty)
Year of House: No, of Bedrooms x Computation = Total Daily Flow
1980 or older x 150 gal/bdrm =
1980— 1991 x 130 gal/bdrm = S U
-1991 —present x _1 LU gal/bdru►.- -- __ — — __�_ -----
Garbage Grinder Installed yes_ / ato
Spa or Whirlpool Installed yes / no
4
4. PARCEL INFORMATION: (circle applicable information & indicate measurements)
era li So' a ur Ground Water Bedrock or Impervious Material _ atcr Stwily
r
s U1e at what clepilr at►vhrr /e/Hh nurniell)(11
ng oam ILIA feet �/�feeI
Steep slope clay T ifivell; water supply
.slope other fl"Ulia CJJay septic-system
depth: absorption is ft.
other
Percolation Test: (7'o be completed by liceiised professional engineer or architect)
Rate: _minute per inch
5. PROPOSED SYSTEM: For New Conslr uclion: All individual sewage disposal systems must be designed by a licensed
professional engineer or architect(unless installed in a Planning l3oard approved subdivision). Add 250 gallons to the size
of the septic tank and leach field for each Garbage Grinder, Spa or Whirlpool Tub.
Septic Tank: I-OQ—O—gallon (min. size 1,000 gal.)
Tile Fiold: each trench 50 fl. Total System Length: r�� fl.
Seepage Pit(s): number of size of each: fl. by fl.
Size of Stono to be used: 11 / depth or thickness
Bed System Size: x
Alteniative System: length and/or size
6, HOLDI K SYSTEM: (if required)
P�G tuber of tanks: / Size of each; gallons /TOTAL Capacity: gallons
S�Vo A1, �ein and associated electrical work must be inspected by a Town approved
�NOF G�� spection agency.
7. N URE &INFORMATION FOR RESPONSIBLE PERSON (please read)
For your protection, please note that pursuant to Section 136-29 of the Code of the Town
of Queensbury, any permit or approval granted which is based upon or is granted in
reliance upon any material misrepresentation or failure to make a material fact or
circumstance known by or on behalf of au applicant, shall be void.
I have read the regulations with respect to this application and agree to abide by these and apt
requirements of the Town of Queensbury Sanitary Sewage Disposal Ordinance.
V
S gnature of responsible pe on Date
V
Septic Inspection Report
Office No. (518) 761-8256 Date Inspection request received: 0 f 00
I
Queensbury Building&Code Enforcement Arrive: anl/ ��jj((��D�//epart: a pm
742 Bay Rd., Queensbury,NY 1,2804 Inspector's Initials.
NAME: e 1�,� PERMIT NO.: Axo4 - 559
LOCATION: IN ON: -
RECHECK:
Comments and/or dia$tram
Soil Type: / Clay
Type of Water: Munic'p /Well Water
Waterline separati istance _ft.
Well separation distance ft.
Other wells: ft.
Absorption Field: Total length
Length of each trench ft.
Depth of trenches ft.
Size of StoneSeepage Pits: Number
Size: x
Stone Size:
Piping Size Type
Building to tank
Tank to Distribution Box S boo— S
Distribution Bo to ield/Pit u L
Opening Sealedl Y/N/Partial
Location/Separations
Foundation to tank ft.
Foundation to absorption
Separation of Pits ft.
Conforms as per Plot Plan V Y N
Location o stem on Property:
(FrontRear Left Side Right Side
Middle Fro Middle Rear r'
S stem Use Stat s•
Approved
Partial Approved and needs to be re-inspected,please call the Building&Codes Office
Disapproved
LASueHemingway\Building.Codes.Inspection.FORMS\Septic Inspection Report.doc January 28,2003
"I have seen or observed, or believe I saw evidence of,
all objects such as houses, -wells, trees, fences, etc.,
shown on this docum,�nt. I also represent that I have
personally measured the distances set forth on the diagram."-
SIGNATURE DATE
T RRfON- f � "� € := ►ftECEI V E"
BUILDING & ® . S EP JUL .16 2004
REVIEWED B TOWN OF BUILDING AND CODE
VC
Dare D
A � �
/.QC/ ffov5c
y l ram:
dr1l
LA./WWI
t �—